Provider Demographics
NPI:1700078912
Name:ROGER MARCELLIN D.D.S. P.C.
Entity Type:Organization
Organization Name:ROGER MARCELLIN D.D.S. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:MARCELLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-293-9100
Mailing Address - Street 1:12011 LEE JACKSON HWY
Mailing Address - Street 2:SUITE 503
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3310
Mailing Address - Country:US
Mailing Address - Phone:703-293-9100
Mailing Address - Fax:
Practice Address - Street 1:12011 LEE JACKSON HWY
Practice Address - Street 2:SUITE 503
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3310
Practice Address - Country:US
Practice Address - Phone:703-293-9100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA5999122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty